The nurse is caring for a client who has become increasingly agitated. He is pacing in the hallway and shouting at other clients. What is the priority action of the nurse?

Attempt to deescalate the client.

Continue to observe the client for increased agitation.

Offer medications to help the client control behavior.

Ensure safety in the environment for the client and others.

Answer and Explanation

The Correct Answer is D

A.   Attempting to deescalate the client is important, but ensuring immediate safety is the top priority.
B.   Continuing to observe the client may lead to a further escalation of the situation. Safety measures should be taken first.
C.   While offering medications may be necessary, ensuring safety is the immediate priority before any interventions are implemented.
D.   Ensuring the safety of the client and others is the priority in situations of escalating agitation.

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Correct Answer is D

Explanation

A. Orienting the client to the unit While orientation is important, the client's prolonged
immobility and stupor necessitate a physical assessment first to ensure there are no underlying medical issues contributing to this state.

B. Reinforcing reality with the client The client's catatonic state may make it difficult to effectively communicate or engage in reality orientation at this point. Addressing potential physical issues is the initial priority.

C. Establishing a nonthreatening relationship Building a therapeutic relationship is crucial, but given the client's current state, assessing for physical problems takes precedence.

D. Assessing the client for physical problems The client's prolonged catatonic state requires an
immediate physical assessment to rule out any underlying medical conditions contributing to his condition.

A. Label the bathroom door. B. Take the older adult to the bathroom hourly. C. Place the older adult in disposable adult briefs. D. Limit the intake of oral fluids to 1000 mL/day.

Correct Answer is A

Explanation

A. Labeling the bathroom door can provide a visual cue to help the older adult locate the bathroom, which may reduce episodes of incontinence.
B. Taking the older adult to the bathroom hourly is a good strategy, but it may not always be feasible or effective in preventing accidents.
C. Using disposable adult briefs may be necessary at times, but it should not be the first line intervention.
D. Limiting oral fluids to 1000 mL/day may lead to dehydration and is not an appropriate intervention for addressing incontinence.

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The nurse is caring for a client who has become increasingly agitated. He is pacing in the hallway and shouting at other clients. What is the priority action of the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is A

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